Josephine van Dongen

7 Evaluation of implementing a targeted rotavirus vaccine program 171 with MRC in secondary and ter tiary care seems not satisfactory for several reasons. Even though information provision was perceived as clear by most of the survey respondents and the majority of HCP believed all eligible infants were routinely informed about rotavirus vaccination, less than 40% of parents stated that they received information on rotavirus vaccination as par t of standard care.This was clarified by the interviews, suggesting that awareness among involved HCP was difficult to achieve. An on-site dedicated physician, as was available for the cohor t- study par ticipants, can offer individual parent counseling, facilitate the information provision and, assist in vaccine planning. This yielded a 87.3% vaccination coverage among the subset of infants par ticipating in the cohor t-study. Fur thermore, recommendation by a HCP is known to be the main driver for choosing vaccination and 80% of parents would visit a HCP to gather information on rotavirus vaccination 25,26 . In addition, significantly fewer parents of unvaccinated infants felt they received information timely. Feeling overwhelmed by information, shor tly before or at the time vaccination decisions have to be made, can lead to refusal 27,28 . In this survey parents and HCP of eligible infants were approached, perspectives of parents or HCP of ineligible infants on HRV vaccination we did not assess.A targeted vaccine program was chosen as preferred vaccination strategy by most survey respondents. However, for delivery of vaccines medical doctors in par ticular favored counseling and vaccine delivery by youth healthcare professionals at well-baby clinics, rather than at the hospital. Endorsement by medical doctors was brought forward as a facilitator during the interviews and suggests a need for collaboration with hospital care. As observed throughout the project by the interviewees, the varying out- patient follow-up policies resulted in individual based vaccine indications, making structured and uniform embedding into standard of care difficult. Only for infants with a GA < 30 weeks or bir thweight below 1000 grams a national follow-up policy is available 29,30 . In addition, uniform recommendations about on-ward rotavirus vaccine administration and off-label use in those <27 weeks GA are needed for consistency in policy and across sites. If a hospital-based targeted vaccination program for medical risk infants is the preferred strategy, we recommend an elaborate educational program for involved HCP as well as integration with the existing NIP structure, which – in the Netherlands - is executed by youth healthcare professionals. In the small group of infants with GA <27 weeks treated in an off-label policy hospital we observed timely vaccination is possible in 86% and with an acceptable safety profile ( chapter 5 ). There were some limitations. First, although offering HRV as par t of standard care to infants with MRC was suggested by the RIVAR protocol, it was not mandatory or structured in a single format. We therefore relied on each par ticipating hospital how they incorporated this new standard of care and supervised execution of the program. As mentioned, we saw a broad variety in on-site protocols which possibly reflected in the achieved vaccination coverage. However in the absence of a national guideline, rotavirus vaccination should be adopted to local policy.Thus, our results reflect real life practice for targeted rotavirus vaccination.